Basic Information
| Provider Information | |||||||||
| NPI: | 1801415443 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFESPAN BEHAVIORAL HEALTH SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2705 SILVER HAMMER WAY | ||||||||
| Address2: | |||||||||
| City: | BROOKEVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208333244 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3416 OLANDWOOD CT STE 201 | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019694060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2020 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | REIDY | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 8008197570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFESPAN BEHAVIORAL HEALTH SERVICES PC | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.